Healthcare Provider Details

I. General information

NPI: 1225316805
Provider Name (Legal Business Name): KAY E HUMPHRIES SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11901 BUSINESS BLVD SUITE 209
EAGLE RIVER AK
99577-7701
US

IV. Provider business mailing address

11901 BUSINESS BLVD SUITE 209
EAGLE RIVER AK
99577-7701
US

V. Phone/Fax

Practice location:
  • Phone: 907-694-6002
  • Fax: 907-694-6015
Mailing address:
  • Phone: 907-694-6002
  • Fax: 907-694-6015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number370
License Number StateAK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: